Nutrition Intake Form

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First name

Last name

Email

Birthday

What are your goals for meal planning?

Are you willing to exercise for at lease 30 minutes 6 days a week? *

Yes

No

Whic htype of meal plan are you looking for? *

Basic (includes both plant and animal-based protein)

Vegetarian (may include eggs / dairy / fish)

Pescatarian (may include eggs / fish)

Dairy-free / Nut-free

Paleo / Gluten-free

Egg-free

Vegan

List any food allergies or intolorances.

List any foods you strongly dislike and DO NOT want in your plan.

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Where science meets soul, and structure meets sustainability.

Our comprehensive programs are designed for individuals ready to reclaim their health through a personalized, culturally grounded, and results-driven approach. We combine clinical insight with compassionate coaching to address the root causes of weight gain, fatigue, and metabolic imbalance.

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416 8th Street

Augusta, GA 30901

info@TheWellnessCo.site

706-739-5985

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Important Medical Disclaimer

These statements have not been evaluated by the FDA. The products and information on this website are not intended to diagnose, treat, cure, or prevent any disease. Compounded medications are not FDA-approved. Results may vary between individuals.

All peptide protocols require a valid prescription from a licensed healthcare provider and are provided through our partner medical clinic. The information provided is for educational purposes only and should not be considered medical advice. Always consult your physician or qualified healthcare provider before starting any new treatment, supplement. or wellness program. Individual results may vary. Never disregard professional medical advice or delay seeking it because of information on this website.

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